The Terraces At Los Altos Health Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for two of 13 sampled residents (Residents 82 and 119) when:For Resident 82, there was a typographical error in his order to monitor urine output; and,For Resident 119, the medical record did not accurately reflect the resident's refusal of a lab test.These failures had the potential to compromise the care and safety of the residents.1. Review of Resident's 82's medical record indicated he was admitted on [DATE] and had diagnoses including bladder cancer, hydronephrosis (swelling of the kidneys caused by a backup of urine), and kidney failure. Further review of the medical record indicated Resident 82 had nephrostomy tubes (small flexible tubes inserted through the skin and into the kidneys to drain urine) in both kidneys. Review of Resident 82's Order Summary Report indicated he had a physician's order, dated 5/31/25, to measure output (amount of urine drained) from the left nephrostomy tube every shift.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) failed to review and revise the fall risk care plan after a fall incident for one of four residents (Resident 1). This failure had the potential to result in Resident 1 experiencing further falls. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses including pathological fracture (broken bones caused by disease) in neoplastic disease, pelvis, unspecified B-cell lymphoma (a type of cancer), severe obesity due to excess calories, and neoplastic related fatigue (persistent feeling of exhaustion caused by cancer and its treatments). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 10/3/24, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level) score was 14 (a score of 13-15 indicates the resident is cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the correct administration of medication when the licensed vocational nurse A entered the medication order to the wrong resident. This failure resulted in one of three sampled residents (Resident 1) receiving a medication that was not prescribed for this resident. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE], with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review on 8/5/24 at 3:38 p.m., with the director of nursing (DON), stated she entered the medication Abrysvo (vaccine that protects against lower respiratory tract disease caused by respiratory syncytial virus [RSV])120 microgram (mcg) /0.5 milliliter (ml -metric unit used to measure volume) to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when: 1. medications were not administered as ordered by the physician; and, 2. Resident 1's physician was not informed regarding missed doses of medication. These failures had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including fractured shaft of right fibula (a break of the larger lower leg bone below the knee joint), atrial fibrillation (irregular heart rate), congestive heart failure (heart cannot pump enough blood to meet the body's needs), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure pressure), presence of cardiac pacemaker (implantable device that regulates heart muscle and contractions) Review of Resident 1's physician's order,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to offer and/or attempt alternatives, explain risks and benefits, or obtain informed consent prior to the use of side rails in accordance with their bed rails (side rails, safety rails, and grab/assist bars) policy for 25 of 25 residents (137, 80, 16, 23, 179, 180, 181, 182, 14, 4, 138, 10, 18, 130, 11, 2, 12, 7, 6, 129, 131, 133, 136, 132, 30). These failures had the potential to place the residents at risk of entrapment and serious injury. For Resident 30, it resulted in the resident's left hand getting caught between the mattress and quarter [one-fourth, one part of a whole divided into four equal parts] side bed rail. Findings: During an observation in Resident 137's room on 4/2/24 at 8:29 a.m., Resident 137 was in bed with bilateral side rails. Review of Resident 137's physician order, dated 3/14/24, indicated he had an order for Side Rails: Quarter. Review of Resident 137's Side Rail Evaluation, dated 3/14/24, indicated bilateral side rails were recommended. There was no documentation that indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facilty failed to ensure sanitary conditions were maintained in the kitchen when: 1. Kitchen staff did not wear hair restraints while in the kitchen; 2. A red bucket was stored on the floor 3. A dietary aide picked up an item from floor and did not perform proper hand hygiene 4. Three of three ice machines had white residue or scale (the buildup of a white, chalk-like substance that forms where water collects or where water is dispensed) . These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1. During an kitchen observation on 4/2/24 at 8:27 a.m., the dishwasher did not have a hair restraint over his hair. During an observation on 4/3/24 at 3:07 p.m., a staff member walked through the kitchen with no hair restraint. During a concurrent observation and interview in the kitchen with the director of dining services (DDS) and nutritional care manager (NCM) on 4/3/24 at 3:18 p.m., the DDS was not wearing a hair restraint. The NCM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the proper agencies per the facility's abuse policy for one of two residents (Resident 23) when Resident 23's abuse allegation was not reported after surveyor notified the administrator (ADM) and executive director (ED). This failure left information relevant to an allegation of abuse unreported to agencies required to be reported to for such allegations. Findings: Review of Resident 23's clinical information yielded a face sheet that indicated she was admitted with diagnoses which included atrial flutter (a type of abnormal heart rhythm, or arrhythmia), muscle weakness, and osteoarthritis (joint pain and stiffness). Resident 23's Minimum Data Set (MDS, an assessment tool) indicated she had full mental capacity per her brief interview of mental status, dated 2/29/2024, with a score of 15 (on a scale of 0-15, 15 being full capacity). During an interview with Resident 23 on 4/02/24 at 8:41 AM, in her room, she stated a nurse on night shift was rough when she was cleaning her.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow a physician's order for one of three sampled residents (Resident 180) when weekly weights were not done as ordered by the physician. This failure of not following a physician's order resulted in the facility to be unaware of Resident 180's weight for over two weeks. Findings: Review of Resident 180's medical record face sheet (summary of important information) indicated she was admitted with diagnoses including pneumonia (an infection that affects one or both lungs) and muscle weakness. A physician's order, dated 3/13/24, was for weekly weights. The Resident Vital Sign Report indicated no documentation of weights since 3/18/24. During interview and concurrent record review with the admissions nurse on 4/9/24 at 2:02 p.m., she stated Resident 180 had no weights taken between 3/18/24 and 4/4/24. Review of the facility's policy titled, Weight Assessment and Intervention, revised 3/2022, indicated, Residents are weighed upon admission and at intervals established by the interdisciplinary team.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a pressure ulcer (damage to the skin caused by prolonged pressure) from developing for one of two residents (Resident 12) when a medical device was not placed properly. This failure resulted in a facility-acquired pressure ulcer for Resident 12. Findings: Review of Resident 12's medical record indicated he was admitted to the facility on [DATE] with a fractured left foot. Review of Resident 12's physician order, dated 2/28/24, indicated to keep left boot on at all times. Review of Resident 12's wound assessment, dated 3/9/24, indicated a facility acquired presssure injury to the left heel was identified on 3/9/24. Review of Resident 12's skin note, dated 3/12/24, indicated the resident was evaluated by the wound specialist on 3/12/24 for medical equipment related wound on his left heel. During an interview on 4/2/24 at 12:09 p.m., registered nurse D (RN D) stated Resident 12 developed a big blister on his heel from his boot about three weeks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to 1. administer all physician ordered medications to one of three residents (Resident 2) when his Miconazole nitrate 2% topical cream (antifungal cream) was not administered during medication administration, and 2. ensure proper accounting of the controlled medication oxycodone (a semi-synthetic narcotic analgesic drug to relieve pain) in one of two medication carts (med cart 1) when the count of the oxycodone whole tablet (tab) and half tab were not correct. These failures had actual (for Resident 2) and potential implications for residents to not receive their prescribed medication(s) correctly. Findings: 1. Resident 2 was admitted with diagnoses which included psoriasis (a chronic (long-lasting) disease in which the immune system becomes overactive, causing skin cells to multiply too quickly. Patches of skin become scaly and inflamed). During an observation of a medication administration on 4/04/24 at 8:23 AM by licensed vocational nurse C (LVN C) for Resident 2, his Miconazole nitrate 2% topical cream was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure two of five residents (Residents 130 and 131) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications. 1. For Resident 130, there was no side effect monitoring and behavior monitoring for the use of trazodone (medication used to treat depression or help with sleep problems); 2. For Resident 131, there was no side effect monitoring and behavior monitoring for the use of trazodone. These failures had the potential to result in lack of adequate monitoring and for the residents to receive unnecessary medications. Findings: 1. Review of Resident 130's medical record indicated he was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions) and hypertension (high blood pressure). Review of Resident 130's physician orders indicated he had an order, dated 3/29/24 for trazodone 50 milligrams (mg, unit of measurement) every bedtime for insomnia (sleep disorder). There was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement infection prevention strategies when: 1. A nurse did not change gloves and perform hand hygiene during one of two dressing changes. 2. One of three urinary catheter bags was on the ground. These failures had the potential to spread infectious organisms to the residents. Findings: During a wound dressing change observation on 4/2/24 at 12:09 p.m., registered nurse D (RN D) prepared Resident 12's wound supplies and put on gloves. RN D removed Resident 12's boot and removed the dressing on his heel. Using the same gloves, RN D cleaned the wound with saline and put on a new dressing. Using the same gloves, RN D cleaned the other wounds on top of Resident 12's foot. RN D did not change gloves or wash or sanitize hands after removing the wound dressing, before cleaning the wound, and before cleaning another wound. During an interview on 4/2/24 at 12:25 p.m., RN D confirmed she only used one pair of gloves throughout Resident 12's wound dressing change. During an interview with the director of staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five residents (Resident 7) was offered and/or received influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and pneumococcal (common bacteria that can affect different parts of the body) vaccinations. This failure increased the potential to for residents to have inadequate immunity to influenza and pneumococcal infections. Findings: Review of Resident 7's clinical record indicated she was 85-years-old and was admitted to the facility on [DATE]. Review of Resident 7's Immunizations Report, dated 4/9/24, indicated she received an influenza vaccination on 11/13/21. There was no documentation that Resident 7 was offered and/or received an influenza vaccination in 2023 or 2024. There was no documentation that Resident 7 was offered and/or received a pneumococcal vaccination. During an interview on 4/9/24 at 11:25 a.m., the director of staff development (DSD) confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure: 1. Two routine pain medications were obtained and administered, as ordered, to meet the needs for one of three sampled residents (Resident 1). The nursing staff failed to call the pharmacy to clarify order changes, and to notify the physician when they ran out of the medications for administration. The failure exposed Resident 1 to unnecessary pain; 2. Two of two controlled medication (those with high potential for abuse and addiction) emergency kits (E-kit: a kit/box containing medications and supplies for immediate use during a medical emergency) were locked in the medication room. This had the potential for loss or abuse of controlled medications; and 3. One of two opened E-kits was replaced timely to ensure availability of medications for resident use in case of an emergency. Findings: 1a. During an interview with the Director of Nursing (DON) on 1/26/24 at 9:20 a.m., she stated Resident 1 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 did not recieve two routine pain medications as prescribed. The failure exposed Resident 1 to unnecessary pain. Findings: a. During an interview with the Director of Nursing (DON) on 1/26/24 at 9:20 a.m., she stated Resident 1 was admitted to the facility on [DATE] with stage 4 cancer and required every-3-hour oxycodone (a potent narcotic for moderate to severe pain) routinely; she was also receiving methadone routinely for pain. The pharmacy only sent enough supply of oxycodone for 3 days. The medication ran out, and Resident 1 missed her first oxycodone dose on 1/12/14 in the evening. On 1/14/24, the night shift nurse texted her and the Administrator early in the morning letting them know he needed the oxycodone for Resident 1. The DON stated she called the physician and asked him to write a new prescription for oxycodone on that day,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. One of one medication refrigerator was identified unlocked when not in use; and its temperature was not being monitored and maintained twice daily as per facility policy and procedures (P&P). This failure could lead to loss of medications, and loss of drug potency due unmonitored temperatures; 2. An opened multi-dose vial did not have an open date. The failure had the potential for the medication being used past its effective date. Findings: 1. During a visit to the medication room with the Director of Nursing (DON) on 1/26/24 at 9:50 a.m., a a medication refrigerator was identified unlocked. A brief review of the contents inside revealed the refrigerator contained numerous medications include a bubble pack containing 30 dronabinol (a controlled medication [those with high potential for abuse and addiction] to treat nausea and vomiting) capsules for a resident, and an emergency kit (a kit/box containing medications and supplies for immediate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 7 of 17 sampled residents (Residents 17, 21, 25, 26, 232, 329 and 330). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes. Findings: 1. Review of Resident 232's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident 232's POLST form indicated the AD section of the POLST was blank. The POLST form did not indicate if there was an advance directive in place or it was not available. Review of Resident 232's POLST indicated the form was prepared on 2/18/23 and Section D: Information and Signatures was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident 14's clinical record indicated he was admitted to the facility on [DATE]. Resident 14 was transferred to the acute hospital on 1/27/23 due to a fever and altered mental status and again on 2/24/23 for critically low hemoglobin (protein in red blood cells that carries oxygen in the bloodstream). Review of Resident 280's clinical record indicated he was admitted to the facility on [DATE]. Resident 280 was transferred to the acute care hospital on [DATE] after sustaining a fall resulting in uncontrolled back pain. Review of Resident 280's clinical record indicated he was discharged from the facility on 12/21/22. Resident 280 was discharged home with home health services. Review of Resident 282's clinical record indicated she was admitted to the facility on [DATE]. Resident 282 was transferred to the acute care hospital on [DATE] after sustaining a fall and suffering a right forehead hematoma (a solid swelling of clotted blood within the tissues) Review of Resident 282's clinical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the controlled substance counting (medications with high potential for abuse or addiction) sign-off sheets for every shift were initialed by license nurses when: Narcotic sign-off sheets were missing initials by licensed nurses for medication carts 1 and 2 This failure had the potential to result in loss, misuse, and accountability for controlled substances. Findings: Review of the facility's forms for controlled substances count for every shift Narcotic Sign-off Sheet (to maintain adequate control and accountability for controlled substances) for the period from 1/31/23 to 3/7/23 (total of 36 days, or 108 shifts) indicated, license nurse's initials were left blank for thirty-one times for medication cart 1. During an interview and concurrent record review with the license vocational nurse B (LVN B) on 3/8/23 at 9:00 a.m., LVN B acknowledged there were several missing nurse's initials for narcotic sign-off sheets. She further stated nurses should have initialed each time when they counted narcotic medications at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened undated, unlabeled, and outdated food items in the reach-in refrigerator and dry storage areas; 2. Pans and plastic containers used for food preparation and food service were stacked and stored wet; 3. Kitchen staff did not know the proper procedures for testing chlorine (chemical) sanitizer used for dishwashing; 4. The dishwasher sanitizing log was not completed; 5. There were no logs recording weekly calibration of thermometers; 6. The temperature of a food item on the steam table was not checked prior to serving during lunch; 7. A scoop was left inside the flour container; 8. There were dented cans of food in the dry storage area; 9. Open bags of food items were not sealed or closed in the walk-in freezer; and, 10. There were opened undated and outdated food items in the food preparation area. These failures had the potential to cause food contamination and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention protocols were followed during multiple occasions, when 1. hand hygiene was not performed between glove changes during wound care, 2. proper PPE (personal protective equipment, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was not worn inside of an isolation room, and 3. hand hygiene was not used during medication pass. These failures had the potential of causing personal and wide spread infections, compromising the health and well-being of all residents and staff in the facility. Findings: 1. During an observation and subsequent interview on 3/8/23 at 2:06 p.m., with licensed vocational nurse B (LVN B), while changing a wound dressing on the right posterior thigh/gluteal border MASD (moisture associated skin damage) of Resident 1, LVN B put on gloves and removed the dressing, then changed gloves without using any form of hand hygiene. LVN B cleaned the wound with normal saline (0.9% sodium chloride), then changed gloves,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) on medications self-administration (residents take medications without staff assistance) and bed side medications storage for two out of 12 sampled residents (Resident 1 and Resident 231) when (a) the facility did not determine that residents were clinically appropriate and safe to self-administer medications, (b) the facility did not ensure self-administered medications were stored in a safe and secure place, and (c)The facility did not obtain a physician order to store medications at bedside. These failures had the potential to result in unsafe medication self-administration. These failures also had the potential to result in other residents gaining unapproved access to the medications. Findings: 1. Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE]. Resident 1's Minimum Data Set (MDS-an assessment tool), dated 1/6/2023, indicated she had a brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the admission baseline care plan for one of 12 residents (Resident 10) was developed in a timely manner, when Resident 10's baseline care plan was not developed within 48 hours of their admission. This failure had the potential of the resident not getting the care she needed and thus having a negative impact on their health and well-being. Findings: Resident 10 was admitted on [DATE], during the day, with diagnoses which included sepsis (the body's extreme response to an infection), pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), acute kidney failure, fracture of medial condyle (located on the inside part of the knee) of left femur (upper leg bone), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 10's care plans, her baseline care plan was not started until 3/25/22, while her admission was on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement person centered and individualized care plans for three out of seventeen sampled residents (Resident 16, 329, and 19) when: 1. Resident 16 had a fall; 2. Resident 329 had a fall and an allegation of abuse, and 3. For Resident 19 there was no care developed after a fall. These failures may delay the implementation of the interventions, identification of specific care areas and services to meet the resident's needs. Findings: 1. Review of Resident 16's clinical record review indicated he was admitted to the facility on [DATE] with diagnosis of cerebral infraction (a result of disrupted blood flow to the brain), cirrhosis of liver (a disease in which healthy liver tissue replaced with scar tissue and the liver permanently damaged), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), atrial fibrillation (a heart condition that causes an irregular and often fast heart rate), and malignant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure to provide care and services according to accepted standards of clinical practice for one of three residents (Resident 25) when: Resident 25's room air oxygen concentrator (RAOC-a machine takes room air and passes it through the filtering system in the machine and converts it to more pure oxygen) was set to deliver oxygen flow at a rate of 3.5 liters per minute (L/min, oxygen flowing into nostrils over a period of one minute) via nasal cannula when Resident 25 had an order for oxygen at 2 liters per minute. This failure had the potential to compromise Resident 25's health and well - being, and not meeting the resident's therapeutic needs or excessive use of oxygen. Findings: Clinical record review indicated Resident 25 admitted to the facility on [DATE] with the diagnosis of acute respiratory failure (a disease or injury affects breathing), pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure two out of five residents (Residents 12 and 279) were free from unnecessary medication when: 1. Resident 12 had physician orders which did not have an indication for the use of Risperdal, a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication, there was no monitoring of her behaviors, and there was no informed consent for the Risperdal. 2. Resident 279 had physician orders which did not have an indication for the use of Seroquel, there was no monitoring of her behaviors, and there was no informed consent for the Seroquel. These failures had the potential of residents receiving psychotropic medications without a need for them. Findings: 1. Resident 12 was admitted with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), delirium (a serious change in mental abilities resulting in confused thinking and a lack of awareness of someone's surroundings), and anxiety disorder. During a review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent or greater when observation of 30 opportunities during the medication administration resulted in two errors (both for Resident 15). The calculation of medication error rate was 6.67 percent. These failures placed Resident 15 at risk for not receiving the full therapeutic effects of medications when medications were not given according to physician's orders. Findings: Clinical review of Resident 15 indicated, the Resident was admitted to the facility on [DATE] with diagnoses that included cerebral infraction due to embolism of right middle cerebral artery (medical condition that occurs when blood flow from the largest artery of the brain suddenly disrupted), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication when: One opened and undated tuberculin purified protein derivative (PPD- a solution used for tuberculin skin test) multi-dose vial was observed in the refrigerator in the medication storage room; This failure had the potential for residents to receive a PPD skin test with reduced potency due to the drug to be potentially past its use-by-date. Finding: During medication room observation and concurrent interview with the interim director of nursing (IDON) on [DATE] at 12:09 p.m., a one fourth full vial of clear solution of PPD multi-dose was opened and undated in refrigerator in the medication storage room. The IDON confirmed this observation. She further stated nursing staff should have labeled the vial with the date for when it was opened. During a phone interview with the facility's consultant pharmacist (CP) on [DATE] at 10:22 a.m., the CP stated nursing staff should have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.